” when tuberculosis bleeds,” A Rare Case of Gastrointestinal Tuberculosis Presenting with Life-Threatening Upper Gastrointestinal Hemorrhage and Severe Cytopenia

Technical Summary: A Rare Case of Gastrointestinal Tuberculosis Presenting with Life-Threatening Upper Gastrointestinal Hemorrhage and Severe Cytopenia

Problem Statement
Gastrointestinal tuberculosis (GITB) is an uncommon manifestation of extrapulmonary tuberculosis that presents significant diagnostic challenges due to its nonspecific clinical presentation, which often mimics peptic ulcer disease, gastrointestinal malignancies, and inflammatory bowel disease. While upper gastrointestinal (GI) hemorrhage is a common medical emergency, it is a rare complication of GITB. The diagnostic difficulty is compounded when acute hemorrhage occurs in patients with constitutional symptoms (e.g., weight loss, anorexia) and hematological abnormalities, leading clinicians to prioritize more common etiologies such as alcohol-related gastropathy or portal hypertension. This case report addresses the critical need to maintain a high index of suspicion for GITB in tuberculosis-endemic settings, even when the primary presentation is life-threatening hemorrhage, to avoid diagnostic delay and ensure appropriate management.

Methodology
This study employs a retrospective single-case report design. The subject was a 61-year-old male with a 30-year history of chronic alcohol consumption who presented with a one-day history of hematemesis and a two-week history of epigastric pain, anorexia, and progressive weight loss.

• Clinical Assessment: The patient underwent a comprehensive physical examination, including vital sign monitoring and assessment of hemodynamic stability.
• Laboratory Investigation: Initial workup included complete blood counts (CBC), liver function tests (LFTs), renal function tests, and electrolyte panels. Notable findings included anemia (Hb 8.8 g/dL), macrocytosis (MCV 101.1 fL), and thrombocytopenia (platelets 75 × 10³/µL).
• Imaging: Chest and abdominal radiographs were performed to evaluate for pulmonary involvement and abdominal pathology.
• Management and Outcome: The patient received standard supportive care for upper GI bleeding (fluid resuscitation, proton pump inhibitors, tranexamic acid) and broad-spectrum antibiotics. Despite these interventions, the patient's condition deteriorated, leading to cardiopulmonary arrest and death. The paper notes that definitive histopathological or microbiological confirmation was not obtained prior to the patient's demise; the clinical impression of gastrointestinal tuberculosis was based on the constellation of symptoms, radiological findings, and the exclusion of other common causes, though the authors explicitly state that the causal relationship between the hemorrhage and TB requires anatomical and pathological support which was not secured.

Key Contributions and Results

• Rare Presentation: The case documents a rare instance where GITB manifested primarily as severe, life-threatening upper gastrointestinal hemorrhage (hematemesis and melena) rather than the more common obstructive or perforative complications.
• Diagnostic Complexity: The patient presented with a complex clinical picture involving chronic alcohol use, thrombocytopenia, and abnormal liver enzymes, which initially suggested alcoholic liver disease or portal hypertension. The report highlights that these comorbidities can obscure the underlying diagnosis of GITB.
• Clinical Course: The patient exhibited constitutional symptoms (fever, night sweats, weight loss) and respiratory symptoms (cough, dyspnea) alongside the GI bleed. Radiological findings suggested pulmonary consolidation and ascites, supporting a systemic infectious process.
• Hematological Findings: The study details the presence of thrombocytopenia and macrocytic anemia, noting that while these could be attributed to alcohol use or liver disease, they also complicated the management of the hemorrhage. The authors explicitly refute the diagnosis of neutropenia based on laboratory data (absolute neutrophil count ~6.6 × 10⁹/L), clarifying that despite the initial clinical assessment listing "neutropenia," the available evidence did not support this diagnosis.
• Outcome: Despite aggressive resuscitation and antimicrobial therapy, the patient died. The report emphasizes that the fatal outcome underscores the severity of the condition and the difficulty in managing such cases without early, specific diagnosis and definitive confirmation.

Significance and Claims
The paper claims that gastrointestinal tuberculosis should remain a critical differential diagnosis for upper gastrointestinal bleeding in patients from tuberculosis-endemic regions, particularly when bleeding is accompanied by unexplained constitutional symptoms such as weight loss and anorexia.

• Diagnostic Vigilance: The authors argue that clinicians must avoid "premature anchoring" on common causes like peptic ulcer disease or alcohol-related pathology when the clinical picture includes persistent constitutional symptoms.
• Management Implications: The report asserts that early hemodynamic stabilization, prompt endoscopic assessment, and appropriate tissue sampling for histopathological and microbiological confirmation are essential for establishing a diagnosis and guiding treatment.
• Educational Value: By presenting a case where GITB mimicked common disorders and resulted in a fatal hemorrhagic event, the paper aims to educate clinicians on the heterogeneity of GITB presentations. It emphasizes that while GITB is rare, its potential to cause catastrophic bleeding necessitates a high index of suspicion in endemic settings to prevent delayed diagnosis and improve patient outcomes.

The authors conclude that while the causal link between the specific bleeding lesion and TB requires histopathological confirmation which was not obtained in this case, the constellation of symptoms strongly suggests GITB as the underlying etiology, highlighting the importance of considering atypical infectious causes in the workup of severe GI hemorrhage.